C-1 Charting Form Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

INFORMED CONSENT

วันที่...................... เดือน.................................... พ.ศ.................................

หนังสือฉบับนีเ้ป็นหลักฐานแสดงวา่

ข้าพเจ้า (นาย / นาง / นางสาว) ........................................................................... อายุ ............. ปี สัญชาติ...............

ในฐานะเป็น (ผู้ป่วย/ผู้มีอ านาจกระท าแทน) เกี่ยวข้องเป็น .........................ของผู้ป่วย ขอแสดงความยินยอมให ้

นักศึกษาทันตแพทย์ ที่ เข้าฝึกปฏิบัติงานในคลินิกทันตกรรมพร้อมมูล สาขาวิชาทันตกรรมทั่วไป ภาควิชา

ทันตกรรมครอบครัวและชุมชน คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่ ท าการรักษาทางทันตกรรมพร้อมมูล

รวมทั้งการฉีดยาชาเฉพาะที่เพื่อประโยชน์ในการรักษา ภายใต้การควบคุมดูแลโดยอาจารย์ทันตแพทย์ หรือ ทันตแพทย์

และหากเกิดความเสียหายใดๆ อันเป็นผลแทรกซ้อนซึ่งเป็นเหตุสุดวิสัยที่เกิดจากการรักษาตามหลักวิชาการ หรือ

การฉีดยาชาเฉพาะที่ดังกล่าว จะไม่เรียกร้องสิทธิใดๆทั้งสิน้ตามกฎหมาย

ข้าพเจ้า ได้รับการอธิบายให้เข้าใจเป็นอย่างดีเกี่ยวกับการรักษาทางทันตกรรมพร้อมมูล การวินิจฉัยโรค

แผนการรักษาทางทันตกรรม การรักษาทางเลือก ค่ารักษา ความเสี่ยงและภาวะแทรกซ้อนที่อาจจะเกิดขึ้น

จากการรักษาทางทันตกรรม

ข้าพเจ้า ยินดีให้ใช้ข้อมูลการรักษาทางทันตกรรมของข้าพเจ้า เพื่อเป็นประโยชน์ทางด้าน งานวิชาการ และ

การเรียนการสอน

ท่านมีสิทธิ์สมบูรณ์ที่จะตัดสินใจยินยอมหรือไม่ยินยอมรับการรักษาทางทันตกรรมพร้อมมูล และให้ท่านลง

ลายมอืชื่อเพื่อเป็นส่วนหน่ึงของหลักฐานประกอบกระบวนการขอความยินยอมในการรักษา

(ลงช่ือ)....................................................................... ผูป้่วย หรือ ผู้มีอ านาจกระท าแทน

(......................................................................)

(ลงช่ือ)....................................................................... อาจารย์ / ทันตแพทย์

(......................................................................)

(ลงช่ือ)....................................................................... พยาน

(......................................................................)

C-2 Charting Form Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

Personal data

Name: ______________________________________________ Age: ___________ Sex: male female

Status: Single Married Divorced Widowed Occupation: __________________ Date of birth: _____________

Address: _____________________________________________________________________________ Zip code: _____________

Home phone: _____________________ Personal phone: _____________________ E-mail: _____________________________

Emergency contact person : ______________________________ Relation: ____________ Phone: ________________________

Date:_______________________ BP ________________ mmHg HR ______________ bpm

Chief complain: _________________________________________________________________________________________________

Medical History

Do you have or Have you had …?

Heart problem

Lung disease

Anemia

GI disease

AIDS

Jaundice

Bleeding disorder

Liver disease

Arthritis

Skin disease

Cancer or Tumor

Injury

High blood pressure

Kidney problem

Joint disease

Venereal disease

Chemotherapy

Diabetes mellitus

Thyroid disorder

Asthma

Rheumatic fever

Radiotherapy

Any other diseases ____________________________________________________________________________________________

Taking medicine ______________________________________________________________________________________________

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Allergic to (Drugs, medicines, substances) ________________________________________________________________________

Habit (smoking, alcohol consumption, bruxism) ____________________________________________________________________

Present Illness __________________________________________________________________________________________________

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Dental History

Frequency of dental visit every 3 month every 6 month every 1 year _______________________

Past dental history

Oral ulceration

TMJ sound or Pain

Complication following dental treatment

Xerostomia

Past jaw or facial injury

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Abnormal Bleeding

Reaction to local anesthesia

Past dental work Restoration Extraction Prosthetic treatment Periodontal treatment

Endodontic treatment Oral medicine TMD Other ___________________________

Additional comments ___________________________________________________________________________________________

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MEDICAL ALERT _____________________________

ALLERGIC TO _____________________________

C-3 Charting Form Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

Clinical examination: Extraoral examination

Front view Symmetrical Asymmetrical Profile form Ovoid Round Square Taper

Lateral Profile Concave Straight Convex

TMJ examination Click : R / L Pain : R / L Deviation : R / L Crepitation : R / L

Dislocation : R / L Overjet: _________ Overbite: ___________ Others : _____________________

Clinical examination: Intraoral examination

Soft tissue examination

Examination report: ________________________________

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Calculus : Slight Moderate Heavy Halitosis : No Yes

High muscle attachment : No Yes : ___________________ Tooth form : Taper Ovoid Square

Occlusion : _____________________________________________________________________________________________________

Occlusal trauma : No Yes : _____________________ Torus / Exostosis : No Yes : _______________________

Oral hygiene : Good Fair Poor Brush type : __________________ Dentifrice : __________________

Technic : __________________ Frequency : ______________ Oral hygiene aids : ___________________________________

Oral habits : Clenching Grinding Bruxing Lip biting Cheek biting

Tongue thrusting Mouth breathing Tooth picking _______________________________

Patient attitude : Good Fair Poor

Overall Prognosis : Good Fair Questionable Poor Hopeless

Tooth contact analysis

MIP / CR 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Protrusion 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Left

Excursion

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Right

Excursion

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

C-4 Charting Form Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

Periodontal Diagnosis ________________________________________________________________________

Pain on percussion:

________________________

Tooth mobility

________________________

Traumatic occlusion

________________________

Malposed tooth

_______________________

Oral habits:

_______________________

การใช้สัญลักษณ ์(symbols)

M : missing

U : unerupted tooth

PE : partial eruption

OE: over eruption of tooth

I : Extracted

การระบายสี (draw)

cavities : blue

filling/RCT/post & core: black

crown/pontic : yellow

gingival margin : green line

pocket depth : red line

Furcation involvement

grade I

grade II

grade III

Bleeding index =_________%

Clinical attachment loss:

1-2 mm คิดเป็น ________ %

3-4 mm คิดเป็น ________ %

≥5 mm คิดเป็น ________ %

C-5 Charting Form Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

Examination Report: ____________________________________________________________________________________________

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BI

PI=___________

C-6 Charting Form Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

Radiographic findings:

Technique Teeth Interpretation

Full Mouth Diagnosis : _____________________________________________________________________________________________

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C-7 Charting Form Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

C-8 Charting Form Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

Phase of Tx Tx plan CDC2 CDC1 M

Systemic

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Emergency

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Disease

control

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Re-

evaluation

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Corrective

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Maintenance

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C-9 Charting Form Planned Treatment Sequence Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

Weeks Planned Treatment

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

C-10 Charting Form Treatment Summary Division of General Dentistry, Department of Family and Community Dentistry

CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..

Student/Date ______________________________________ Instructor/Date __________________________________________

Treatment finished To be continued

Student Name ______________________________________________________ Code ________________________________________

Group__________________ Advisor ______________________________ Prosthodontic Consultant __________________________

Type of patient continue CDC2 CDC1 M

referral to _______________ Details _______________________________________________________________

discharge

Next appointment _________________________________________________________________________________________________